Los Angeles Unified School District

Parent/Guardian Publicity Authorization and Release

Dear Parent/Guardian:

The Los Angeles Unified School District requests your permission to reproduce through printed, audio, visual, or electronic means
activities in which your pupil has participated in his/her education program. Your authorization will enable us to use specially
prepared materials to (1) train teachers and/or (2) increase public awareness and promote continuation and improvement of
education programs through the use of mass media, displays, brochures, websites, etc.
1. Name of Pupil (please print) 2. Birthdate (please print)

3. Name of Parent (please print)

a. I, as a parent of guardian, of the above named pupil fully authorize and grant the Los Angeles Unified School District and its
authorized representatives, the right to print, photograph, record, and edit as desired, the biographical information, name,
image, likeness, and/or voice of the above named pupil on audio, video, film, slide, or any other electronic and printed formats,
currently developed, (known as “Recordings”), for the purposes stated or related to the above.

b. I understand and agree that use of such Recordings will be without any compensation to the pupil or the pupil’s parent or
guardian.

c. I understand and agree that the Los Angeles Unified School District and/or its authorized representatives shall have the
exclusive right, title, and interest, including copyright, in the Recordings.

d. I understand and agree that the Los Angeles Unified School District and/or its authorized representatives shall have the
unlimited right to use the Recordings for any purposes stated or related to the above.

e. I hereby release and hold harmless the Los Angeles Unified School District and its authorized representatives from any and all
actions, claims, damages, costs, or expenses, including attorney’s fees, brought by the pupil and/or parent or guardian which
relate to or arise out of any use of these Recordings as specified above.
__________________________________________________________________________________________________________
My signature shows that I have read and understand the release and I agree to accept its provisions.

4. Signature of Parent/Guardian 5. Date Signed

6. Address (Number, Street, Apartment Number)

7. City 8. State 9. Zip Code

10. Telephone

Granting of permission is voluntary. Please return completed form to school.

11. Principal Approved as to form by the
Office of the General Counsel.

This form shall not be amended without

12. School written approval of both the Office of the
General Counsel and the Office of
Communications/Public Information